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PICTURES IN CLINICAL MEDICINE
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Systemic AL Amyloidosis with Colonic Submucosal Hematoma Sho Sasaki 1, Jun Nishikawa 2, Shinichi Hashimoto 1 and Isao Sakaida 1 Key words: AL amyloidosis, submucosal hematoma
(Intern Med 56: 741-742, 2017) (DOI: 10.2169/internalmedicine.56.7756)
Picture 2. Picture 1.
Picture 4.
Picture 3.
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Department of Gastroenterology & Hepatology, Yamaguchi University Graduate School of Medicine, Japan and ２ Department of Laboratory Science, Yamaguchi University Graduate School of Medicine, Japan Received for publication May 25, 2016; Accepted for publication July 14, 2016 Correspondence to Dr. Sho Sasaki, [email protected]
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Intern Med 56: 741-742, 2017
DOI: 10.2169/internalmedicine.56.7756
An 80-year-old man hospitalized with acute chronic heart failure had received anticoagulant therapy for atrial flutter and passed bloody stools. Warfarin was used, and the International Normalized Ratio (INR) was controlled at 1.91. Urgent colonoscopy revealed multiple colonic submucosal hematomas (Picture 1). Colonoscopy repeated one week after discontinuing anticoagulant therapy showed smaller and flatter submucosal hematomas and the development of shallow ulcers (yellow arrows) (Picture 2). A histopathological examination of biopsy specimens showed eosinophilic material positive for Congo red staining deposited mainly in the submucosal layer (Picture 3). Immunohistochemistry was positive for lambda light chain (Picture 4). The findings for serum M protein and IgA lambda type were positive, consistent with a diagnosis of systemic AL amyloidosis. The patient’s heart failure was thought to be caused by left ventricular diastolic dysfunction due to amyloid deposition. Systemic AL amyloidosis with colonic submucosal hematoma is rare (1). AL amyloid within the vascular walls in-
creases the vessel fragility and risk of collapse, resulting in hematoma formation (2). In this case, anticoagulant therapy worsened the hematomas. The authors state that they have no Conflict of Interest (COI).
References 1. Matsuda M, Katoh N, Ikeda S. Clinical manifestations at diagnosis in Japanese patients with systemic AL amyloidosis: a retrospective study of 202 cases with a special attention to uncommon symptoms. Intern Med 53: 403-412, 2014. 2. James DG, Zuckerman GR, Sayuk GS, Wang HL, Prakash C. Clinical recognition of Al type amyloidosis of the luminal gastrointestinal tract. Clin Gastroenterol Hepatol 5: 582-588, 2007. The Internal Medicine is an Open Access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. To view the details of this license, please visit (https://creativecommons.org/licenses/ by-nc-nd/4.0/).
Ⓒ 2017 The Japanese Society of Internal Medicine http://www.naika.or.jp/imonline/index.html
742
PICTURES IN CLINICAL MEDICINE
□
Systemic AL Amyloidosis with Colonic Submucosal Hematoma Sho Sasaki 1, Jun Nishikawa 2, Shinichi Hashimoto 1 and Isao Sakaida 1 Key words: AL amyloidosis, submucosal hematoma
(Intern Med 56: 741-742, 2017) (DOI: 10.2169/internalmedicine.56.7756)
Picture 2. Picture 1.
Picture 4.
Picture 3.
１
Department of Gastroenterology & Hepatology, Yamaguchi University Graduate School of Medicine, Japan and ２ Department of Laboratory Science, Yamaguchi University Graduate School of Medicine, Japan Received for publication May 25, 2016; Accepted for publication July 14, 2016 Correspondence to Dr. Sho Sasaki, [email protected]
741
Intern Med 56: 741-742, 2017
DOI: 10.2169/internalmedicine.56.7756
An 80-year-old man hospitalized with acute chronic heart failure had received anticoagulant therapy for atrial flutter and passed bloody stools. Warfarin was used, and the International Normalized Ratio (INR) was controlled at 1.91. Urgent colonoscopy revealed multiple colonic submucosal hematomas (Picture 1). Colonoscopy repeated one week after discontinuing anticoagulant therapy showed smaller and flatter submucosal hematomas and the development of shallow ulcers (yellow arrows) (Picture 2). A histopathological examination of biopsy specimens showed eosinophilic material positive for Congo red staining deposited mainly in the submucosal layer (Picture 3). Immunohistochemistry was positive for lambda light chain (Picture 4). The findings for serum M protein and IgA lambda type were positive, consistent with a diagnosis of systemic AL amyloidosis. The patient’s heart failure was thought to be caused by left ventricular diastolic dysfunction due to amyloid deposition. Systemic AL amyloidosis with colonic submucosal hematoma is rare (1). AL amyloid within the vascular walls in-
creases the vessel fragility and risk of collapse, resulting in hematoma formation (2). In this case, anticoagulant therapy worsened the hematomas. The authors state that they have no Conflict of Interest (COI).
References 1. Matsuda M, Katoh N, Ikeda S. Clinical manifestations at diagnosis in Japanese patients with systemic AL amyloidosis: a retrospective study of 202 cases with a special attention to uncommon symptoms. Intern Med 53: 403-412, 2014. 2. James DG, Zuckerman GR, Sayuk GS, Wang HL, Prakash C. Clinical recognition of Al type amyloidosis of the luminal gastrointestinal tract. Clin Gastroenterol Hepatol 5: 582-588, 2007. The Internal Medicine is an Open Access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. To view the details of this license, please visit (https://creativecommons.org/licenses/ by-nc-nd/4.0/).
Ⓒ 2017 The Japanese Society of Internal Medicine http://www.naika.or.jp/imonline/index.html
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![[Nail abnormalities revealing AL systemic amyloidosis].](/assets/img/hold.png)
